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Conquering the ICD-10 Documentation Challenge
Barbara Oviatt, CPC, CCS-P
Purpose
Develop a transition process to prepare clinicians to document
in an ICD-10 environment
Objectives• Evaluate the documentation impact of
ICD-10• Review significant coding guideline
variations between ICD-9 and ICD-10 • Demonstrate effective use of GEMs • Develop an effective chart review
strategy
Documentation Matters!
Documentation Matters!• Provider’s responsibility• Facilitates continuity of care• Supports the claim – Diagnosis codes– CPT codes– Modifiers
• Will be impacted by ICD-10• Begin awareness campaign and chart
reviews now
Chart Review Process
• Establish review team members• Identify goals and objectives• Determine the sample• Conduct the chart review• Educate• Re-review
Chart Review Process
• Determine the sample• Frequently reported ICD-9 codes• Identify top 20 diagnosis
– Generate code lists by specialty– Analyze and adjust the list as needed
• Establish sample size – Include all providers who code or whose
documentation is the basis for code assignment– Number of codes per provider – Number of charts per code / provider
Analyze Your Top 20
• Identify the top 20 codes for each specialty and / or provider
• Review the GEMs mapping for each code– Review the additional codes in the category– Note the necessary documentation elements– Note any pertinent coding guidelines
• Adjust code selections and revise list as necessary
What is GEMs?
• General Equivalency Mappings• Developed by CMS• Not a crosswalk!• Attempts to find corresponding
diagnosis codes between I-9 and I-10• Often maps to an unspecified code
GEMs Example
Avoid the Unspecified Trap• GEMs often leads to unspecified code
maps– Unspecified can lead to unpaid– Denied for medical necessity– Denied because you should know if it was
the left or right– Look for specific alternatives within the
code category
Asthma
GEMs Map:
Unspecified to unspecified; search the category for a better alternative.
CATEGORY
SEARCH
Asthma
ICD-9-CM = 493.90• Extrinsic vs. intrinsic• Chronic obstructive asthma• With status asthmaticus• With exacerbation• Exercise induced
bronchospasm• Cough variant asthma
Additional documentation required
ICD-10-CM = J45.909• Mild intermittent • Mild persistent • Moderate persistent • Severe persistent • With status asthmaticus• With exacerbation• Exercise induced bronchospasm• Cough variant asthma• Tobacco use or exposure
(additional code required) Notes:• Excludes chronic obstructive
asthma
Tobacco Use and ExposureNumerous instructions to use additional code identifying tobacco use or exposure, if applicable
NEW!
Exposure
Z77.22 - Environmental
Z57.31 - Occupational
P96.81 - Perinatal
Use
O99.33 – Complicating
pregnancy
Z72.0 - Nondependent
Z87.891 - History
Nicotine Dependence
Category F17
Cigarettes, chewing
tobacco, other
Remission, withdrawal,
other disorder
Hypertension
GEMs mappings:
CATEGORY
SEARCH
Hypertension
Gems mappings:
PARTIAL CATEGORY SEARCH - I1
Hypertension
ICD-9: 401.X – 404.x• Benign• Malignant• Hypertensive heart disease• Hypertensive CKD • Hypertensive heart and CKD• Secondary hypertension
– Renovascular• Indicate as appropriate
– With / without heart failure – Type of heart failure– Stage of CKD
Additional documentation required
ICD-10: I10 – I15.x• Essential (without comorbidities)• Comorbidities Present
– Hypertensive heart disease– Hypertensive CKD – Hypertensive heart and CKD– Secondary hypertension
• Renovascular, endocrine• Underlying condition
– Indicate as appropriate• With / without heart failure • Type of heart failure• Stage of CKD
• History of use, current use of, or exposure to tobacco
• Distinguish between hypertension and high blood pressure without diagnosis of HTN (coded with R03.0)
Other Common Features• Significant expansion of combination
codes that will require documented specificity of conditions– E20.21 Type I diabetes mellitus with diabetic
nephropathy– I25.110 Atherosclerotic heart disease of native
coronary artery with unstable angina pectoris– K50.112 Crohn’s disease of large intestine with
intestinal obstruction
Other Common Features• Placeholder character– T42.4x5A Adverse effect of benzodiazepines, initial
encounter
• Always the letter “x”• Used to keep other characters in their place
5th digit is a place holder6th digit indicates external cause7th digit indicates episode of care
Other Common Features
• Episode of care is associated with various injuries throughout ICD-10– M80.08A Age related osteoporosis with current
pathological fracture, vertebra(e), initial encounter– S61.421D Laceration with foreign body of right
hand, subsequent encounter– T21.31xS Burn of third degree of chest, sequela
There are 16 episode of care extensions associated with fractures
W56.02XA Struck by a Dolphin, Initial Encounter
Other Common Features
• Codes reflect laterality when appropriate:– H60.332 Swimmer’s ear, left ear– S63.411A Sprain of carpal joint of right
wrist, initial encounter– H65.06 Acute serous otitis media, recurrent,
bilateral
Conduct the Chart Review
• Assess the documentation – Potential ICD-10 code assignment– Note strengths and weaknesses– Identify educational needs– Identify process issues
Chart Review Follow Up• Educate– Deliver positive feedback to providers– Be prepared and stay focused
• Use effective methodology– Lunch and learn meetings– Contests– Flashcards– Diagnosis of the week campaign
• Address needs– Template revisions, etc.
Chart Review Follow Up• Monitor on established timeline– Re-review for improvement– Re-educate as necessary– Evaluate effectiveness of strategy
• Repeat– Select the next code or re-review– Educate– Address needs– Monitor
Evaluate
Review
AnalyzeEducate
Re-review
Chart Review Recap
Questions…
